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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: JJGC S.A. CM DRIVE IMPLANT, TITANIUM, 3.5X16 MM; ENDOSSEOUS DENTAL IMPLANT
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JJGC S.A. CM DRIVE IMPLANT, TITANIUM, 3.5X16 MM; ENDOSSEOUS DENTAL IMPLANT Back to Search Results
Model Number 109.996
Medical Device Problem Code Failure to Osseointegrate (1863)
Health Effect - Clinical Code Fibrosis (3167)
Date of Event 01/07/2021
Type of Reportable Event Serious Injury
Event or Problem Description
The clinician reports the implant was inserted (b)(6) 2019 in ada 5.On (b)(6) 2021, non-osseointegration was verified.Patient presented with poor oral hygiene.The device was forwarded to the manufacturer.At the event the patient experienced: mobility.No further patient complications were reported.
 
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Brand Name
CM DRIVE IMPLANT, TITANIUM, 3.5X16 MM
Common Device Name
ENDOSSEOUS DENTAL IMPLANT
Manufacturer (Section D)
JJGC S.A.
av. juscelino kubitschek de
oliveira, 3291 cic
curitiba PR 81270 -200
BR  81270-200
MDR Report Key11359588
Report Number0001222315-2021-02891
Device Sequence Number17173098
Product Code DZE
UDI-Device Identifier07899878023357
UDI-Public07899878023357
Combination Product (Y/N)N
Initial Reporter StateTN
Initial Reporter CountryUS
PMA/510(K) Number
K123022
Summary Report (Y/N)Y
Device Implanted Year2019
Device Explanted Year2021
Serviced by Third Party (Y/N)N
Reporter Type Manufacturer
Initial Reporter Occupation Dentist
Type of Report Initial
Report Date (Section B) 02/22/2021
Report Date (Section F) 01/27/2021
1 Device was Involved in the Event
1 Patient was Involved in the Event
Is this an Adverse Event Report? Yes
Is this a Product Problem Report? No
Operator of Device Health Professional
Device Expiration Date11/18/2022
Device Model Number109.996
Device Catalogue Number109.996
Device Lot Number800328457I
Was Device Available for Evaluation? Device Returned to Manufacturer
Date Returned to Manufacturer01/27/2021
Was the Report Sent to FDA? No
Distributor Facility Aware Date02/22/2021
Device Age38 MO
Event Location Other
Date Report to Manufacturer01/27/2021
Type of Report(Section G)Thirty-Day
Initial Date Received by Manufacturer 01/27/2021
Initial Report FDA Received Date02/22/2021
Is This a Single-Use Device that was
Reprocessed and Reused on a Patient? (Y/N)		 No
Patient Sequence Number1
Outcome Attributed to Adverse Event Required Intervention;
Patient Age69 YR
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